National HIPAA Audioconference: Analysis of the National Provider Identifier

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National HIPAA Audioconference Analysis of the
National Provider Identifier

• NPI Enumeration Strategies
• Gail Kocher, Highmark Inc
• January 11, 2006

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Individual Practitioner

• One NPI for lifetime
• Required when covered entity, i.e. sole
  proprietorship

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Individual Practitioner

• Highly recommended for all, but specific
  examples, when
• A member of group professional practice
• Hospital compensated or facility employed
• Routinely refers patients to other Health Care
  Providers

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Organizational Provider

• Required for covered entity Health Care Providers
  when they are the
• Legal entity
• Subpart that would be a covered entity if a
  separate legal entity
• Subpart that generates its own standard
  transactions

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Organizational ProviderEnumeration Strategy

• One schema for all Payers
• Requires communication between Providers and
  their Payers
• Requires determination of business need vs.
  mandated need for subparts
• Provider Decision
• Enables Coordination of Benefits

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Organizational ProviderEnumeration Strategy

• Highest level of granularity detail needed for
  internal business processes
• Evaluate current contracts for reimbursement
  impacts
• Determine potential contract changes for
  reimbursement impacts
• Evaluate systems capabilities and limitations

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Organizational ProviderEnumeration Strategy

• Highest level of granularity detail needed for
  internal business processes
• Determine internal billing entity needs
• Billing Provider
• Returned Data e.g. remit, utilization
• Determine Payer capabilities
• Data supplied e.g. remit, utilization

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Organizational ProviderEnumeration Strategy

• Highest level of granularity detail needed for
  internal business processes
• Criteria for uniqueness must be met e.g..
  Taxonomy, Location
• Be aware of potential future HIPAA transaction
  impacts, e.g.. 005010

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Contact Information

• Gail Kocher HIPAA Knowledge Center Highmark,
  Inc. 717-302-4908 gail.kocher_at_highmark.com